Amended in Senate May 27, 2014

Amended in Senate April 10, 2014

Senate Bill No. 986

Introduced by Senator Hernandez

February 11, 2014

An act to add begin insert and repeal end insert Section 14103.9 begin delete to end delete begin insert of end insert the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL’S DIGEST

SB 986, as amended, Hernandez. Medi-Cal: managed care: exemption from plan enrollment.

Existing law provides for the Medi-Cal program, administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. One of the methods by which these services are provided is pursuant to contracts with various types of managed care health plans.

This bill would begin insert , until January 1, 2018, end insert require that a Medi-Cal beneficiary who has received a medical exemption from enrollment in a Medi-Cal managed care plan and who is to receive or has received specified transplantations, including allogeneic bone marrow transplantation, receive an extension of the medical exemption for up to 12 months if the treating physician who provided or oversaw the transplantation or who is providing the followup care determines that it is medically necessary for the beneficiary to remain under the care of the treating physician. The bill would require, at the end of the extension, the treating physician to assess the beneficiary’s condition to determine whether the beneficiary’s condition has stabilized to a level that would enable the beneficiary to be safely transferred to a physician within a Medi-Cal managed care health plan without any deleterious effects to the beneficiary’s health. If the condition is not stable enough to transfer, the medical exemption would be extended up to an additional 12 months. The bill would prohibit a beneficiary meeting the criteria of these provisions from being transitioned into a Medi-Cal managed care health plan until appeals and other specified means of redress have been exhausted. The bill would make related findings and declarations.

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.

The people of the State of California do enact as follows:

SECTION 1.  

The Legislature finds and declares all of the
following:

(a) Medi-Cal beneficiaries with severe conditions have
difficulties finding specialists and centers of excellence to treat
them. Even when they do find this care, Medi-Cal beneficiaries
often lose continuity of care with these providers due to regulations
pertaining to the medical exemption from enrollment in a Medi-Cal
managed care plan process, which leads to delays in obtaining
care, inability to maintain continuity with specialists with the
knowledge required to treat their conditions, and a painful and
costly worsening or relapse of their medical conditions.

(b) It is important that Medi-Cal beneficiaries maintain
continuity of care with their specialty care providers when the
beneficiary has been diagnosed with cancer or other life-threatening
blood disorders or undergone bone marrow, blood stem cell, cord
blood, or haploidentical transplantation.

(c) Bone marrow, blood stem cell, cord blood, and haploidentical
transplantation, particularly allogeneic transplants in which the
marrow or stem cells of an unrelated donor are used, can create
significant complications for the patient long after the initial
hospital stay. Medi-Cal beneficiaries on immunosuppressive
medications, if not properly monitored, can suffer significant
adverse reactions, including relapses of their original cancer or
blood disorder, graft versus host disease, and rare infections that
can be severe, disabling, and fatal. When these complications
occur, they are not only significantly painful and distressing to the
beneficiary and his or her loved ones, but add tremendous,
preventable costs to the Medi-Cal system.

(d) Therefore, the Legislature finds that it is in the best interests
of Medi-Cal beneficiaries who have undergone allogeneic bone
marrow, blood stem cell, cord blood, or haploidentical
transplantations to maintain continuity of care with these specialty
care providers when those providers certify the need for continuity
and can appropriately monitor and treat their conditions and
comorbidities. The Legislature also finds that it in the best interests
of the beneficiaries, the Medi-Cal system, and the taxpayers of
this state that this more cost-effective continuity of care is
maintained, thereby preventing costly, disabling, and even fatal
adverse reactions, relapses, and infection.

SEC. 2.  

Section 14103.9 is added to the Welfare and
Institutions Code, to read:

14103.9.  

(a) A Medi-Cal beneficiary who has received a
medical exemption from enrollment in a Medi-Cal managed care
plan pursuant to the medical exemption request process, as
provided for in Section 53887 of Title 22 of the California Code
of Regulations, and who is to receive or has received an allogeneic
bone marrow transplantation, allogeneic blood stem cell
transplantation, cord blood transplantation, or haploidentical
transplantation shall receive an extension of the medical exemption
beyond the initial 12-month exemption period if the treating
physician who provided or oversaw the transplantation or who is
providing the followup care to the beneficiary determines that it
is medically necessary for the beneficiary to remain under the care
of the treating physician. The extension shall be provided for up
to 12 months, after which the treating physician who provided or
oversaw the transplant, or who is providing the followup care,
shall assess the beneficiary’s condition to determine whether the
beneficiary’s medical condition has stabilized to a level that would
enable the beneficiary to be safely transferred to a physician within
a managed care health plan without any deleterious effects to the
beneficiary’s health.

(b) If, at the end of the extension pursuant to subdivision (a),
the treating physician determines that the beneficiary’s condition
is not sufficiently stable to enable a transfer without deleterious
effects to the beneficiary, the medical exemption shall be extended
for up to an additional 12 months, after which another assessment
shall be conducted pursuant to the process described in subdivision
(a). A beneficiary meeting the criteria of subdivision (a) who
requests an extension of a medical exemption shall not be
transitioned into a Medi-Cal managed care plan until all appeals,
fair hearings processes, litigation, and other means of redress have
been exhausted.

(c) The existence of a contract between the provider or
provider’s medical group and a Medi-Cal managed care plan, or
a contract between the hospital that provided the transplantation
or followup care and a Medi-Cal managed care plan, or the
beneficiary’s prior enrollment in a managed care plan shall not be
considered as a factor in determining the extension of a medical
exemption request pursuant to this section for beneficiaries who
have received the procedures specified in subdivision (a). The
contracts shall not be used as a reason or basis for returning a
beneficiary who has received one or more of these procedures to
a Medi-Cal managed care plan.

(d) For the purposes of this section, the following definitions
shall apply:

(1) “Allogeneic bone marrow transplantation” means the
transplantation of bone marrow from an immunologically matched
sibling or an unrelated donor following treatment with one or more
of the following therapies: chemotherapy, radiation therapy, or
immunotherapy.

(2) “Allogeneic blood stem cell transplantation” means
transplantation of growth factor mobilized blood stem cells from
an immunologically matched sibling or unrelated donor following
treatment with one or more of the following therapies:
chemotherapy, radiation therapy, or immunotherapy.

(3) “Cord blood transplantation” means transplantation of
umbilical cord blood cells from partially or fully immunologically
matched and previously collected cord blood following treatment
with one or more of the following therapies: chemotherapy,
radiation therapy, or immunotherapy.

(4) “Haploidentical transplantation” means transplantation of
bone marrow or growth factor mobilized blood stem cells from a
partially matched familial donor following treatment with one or
more of the following therapies: chemotherapy, radiation therapy,
or immunotherapy.

begin insert

(e) This section shall remain in effect only until January 1, 2018,
and as of that date is repealed, unless a later enacted statute, that
is enacted before January 1, 2018, deletes or extends that date.

end insert